Step 1: Patient Positioning
The patient is placed in a lateral decubitus position. The chest wall is palpated, and clinical correlations are made with the CT scan to confirm the location of the rib fracture(s). The chest is prepped and draped in a sterile fashion. The lung is deflated by the anesthesiologist via a dual-lumen endotracheal tube and a 30° thorascope is placed anterior medially to help localize the area(s) of injury and to assist with proper plate placement.
Step 2: Exposure
Approximately 10 cm oblique incision is made over the rib fracture. The subcutaneous tissues and muscles are divided with cautery. The retromuscular space between the muscle and the ribs is opened with blunt dissection and adhesions are taken down with cautery. The rib is isolated for a distance of 2 cm on either side of the fracture and the musculature is then subperiosteally elevated off the bone fragments. It is important to keep soft tissue attachments to the fragments in an attempt to maintain vascularity. Care should also be taken to avoid injury to the neurovascular bundle along the inferior margin of the rib. The ends of the fracture can be rongeured as necessary and the fracture is reduced into position.
Step 3: Rib Measurement & Plate Selection
The thickness of the rib is measured using the thickness gauge by placing the curved tip over the rib near the fracture site in a superior to inferior direction. Slide the sleeve forward to make contact with the rib. Read the measurement from the gauge and note the color (blue, green, fuchsia) and/or size and select a plate that matches.
Step 4: Targeting Guide & Plate Assembly
Two targeting guides are assembled to the plate by aligning the pins of the guides with the holes in the plate and tightening the fasteners firmly.
Step 5: Contour Plate
The plate with targeting guides is placed centrally over the fracture in a superior to inferior direction. If contouring of the plate is necessary to match the curvature of the rib, grasp the targeting guides with both hands and bend the plate using an outward arcing motion until the curvature of the plate matches that of the rib.
Step 6: Drill Bone for Screw Insertion
While maintaining fracture reduction, select the correct drill guide that matches the color of the plate and insert into barrel #1 of the targeting guide. Use the provided drill bit under power to create the first screw hole in the rib. Advance drill until it bottoms out on the drill guide. Remove drill and drill guide from targeting guide.
Step 7: Secure Plate to Rib
Select the correct screw length by matching the screw color with the plate color and insert through the targeting guide barrel using hex driver with screw sleeve. Pull the sleeve off the screw head as screw is inserted through guide. Tighten screw until snug. Repeat drilling and screw insertion sequentially in targeting guide barrels 2, 3, and 4 until all four screws are inserted.
Note:It is important not to over tighten once all four screws are inserted as this may cause the screw or plate to strip.
Step 8: Final Adjustments
Once all four screws are inserted, both targeting guides are removed by loosening the fasteners. The fasteners will remain contained within the targeting guides. Check the tightness of the bone screws by tighting a pair of screws on each side of the fracture ¼ turn at a time. The thorascope can be used to visualize the internal fracture fixation.
Closure and Post-Op Protocol
A chest tube is placed through the thorascopic port site and secured. If possible the retromuscular fatty tissue is then closed over the plate. The musculature is closed with suture. A closed suction drain is placed in the retromuscular space prior to muscle closure to prevent seroma formation. The subcutaneous tissues are closed and the skin is then closed with subcuticular stitch.
Daily chest radiographs are taken for two to three days post-operatively to confirm plate fixation stability. Intravenous antibiotics are given until the drains are removed. Patients are counseled to avoid vigourous physical activity such as lifting and sports for at least one month and follow-up chest radiographs are obtained in the outpatient setting at two weeks post-op and as needed thereafter.